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Addiction Often Requires Medication

Several years ago I worked with a highly intelligent, sophisticated couple who were severely addicted to heroin. Month after month they struggled to stop, but over and over they found themselves “chasing the high” by taking larger amounts of intravenous heroin or scoring smaller amounts just to keep themselves functional. Finally, they left the States and moved to a kibbutz for a year. They went through a difficult and painful withdrawal syndrome but then lived a drug-free but isolated life for over a year. Having the sense that they had finally licked the addiction, they returned to the United States. Upon arrival at JFK airport, they could think about little else than getting heroin. They both broke into cold sweats, developed goose bumps on their skin and had to run to the bathroom with diarrhea. They hadn’t used drugs for over a year and yet the mere access to their old lives stirred craving so intense that they had the classic signs and symptoms of opiate withdrawal. Within hours they had returned to their lives of addiction.

I don’t know what happened to them after I moved to Martha’s Vineyard 18 years ago, but today they would have the relatively new option of taking buprenorphine (Suboxone and Subutex). Suboxone, like methadone, heroin, Oxycontin and several other medications, is an opioid. But there are a few key differences between Suboxone and the other opiates. The most important is that it is legal for specially licensed physicians to prescribe it to opiate addicts so that they don’t need street drugs. Suboxone binds so strongly to the opiate receptor that once an addict is on it, drugs like heroin have minimal, if any, effect. Suboxone lasts a long time, blocks craving and doesn’t typically induce a high. And it seems to also block craving for alcohol and other drugs.

There is considerable debate about whether these replacement medications are a crutch that allows drug users to substitute a legal drug for an illegal one. As a prescriber of these medications, I have found that most of my patients are living sober, healthy lives. But all too often they struggle with whether to keep their treatment secret from their doctors, families and sponsors out of fear that they will be judged and shamed by people who consider their sobriety a sham.

In studies of people who are maintained on adequate doses of long-acting opiates like Methadone and Suboxone, there is less use of other drugs, less criminal activity and more engagement in work, family and love. Safer, legal replacement medications allow addicts to live healthy and productive lives. The down side? They can be as hard to get off of as heroin. Some people divert their medications — that is, sell their supply on the street. Replacement medications decrease the motivation to get completely clean, and they require the prescribing physician to be vigilant about abuse, diversion and other drug use. People taking these medications are dependent on the prescriber for as long as they are on them, and they must submit themselves to regular urine screens.

Suboxone is not for every opiate addict. The people I see who are on Suboxone are generally motivated, hardworking and committed to sobriety. They tend to have occupations and families, and most have gone regularly to twelve-step programs.

Despite the fact that individuals on Suboxone are by and large responsible, sober, moral members of society, many feel that they cannot tell their families, employers, fellow Alcoholics or Narcotics Anonymous members about their use of Suboxone. Many feel stigmatized by their pasts and ashamed of the need for Suboxone. That sense of shame is reinforced by people who judge them because of a lack of understanding.

Judgment about people who seek other forms of help such as psychotherapy and antidepressants seems to be fading. Hopefully, the time will come when the judgment toward individuals who need medication for their addictions will fade as well.

Dr. Charles Silberstein is on the psychiatrist board in addiction and general psychiatry with offices at Martha’s Vineyard Hospital.

Comments (4)

Chilmarker, Chilmark

The highly intelligent, sophisticated (and likely well-off) heroin addicts could have tried maintaining their detoxed lives with a long-term clean diet, yoga, meditation, and the correct kind of individualized support they clearly lacked. Why was this couple successfully living sober while on a Kibbutz, separated from all the drugging influences they chose for themselves at home? It certainly wasn't because of an "addiction specialist" shrink back in NY. Westernized medicine that thinks it can cure the body of addictions with pills is just wrong. It may be impossible to convince any shrink who benefits from having these kinds of patients, but it is entirely possible, indeed preferable, to treat even the most difficult addictions without using more drugs, except during the medically necessary detox period and initially to wean the addict without adding suffering. I save my judgement not for the addicts, but for the pill pushing pawns of drug companies who are charging upwards of 300 dollars per 45 minutes for the honor of prescribing deadly drugs with side-effects to keep their addict patients as addicts, but safe addicts. Dr. Silberstein makes it sound as if adding more addicting pills would be an easy fix for addicts, were it not for all the judgmental loved ones surrounding the addict who want to see their loved one clean. With doctors like this around, these addicts will never be free and clean. I am sorry to say that the excuses in this essay remind me very much of the many island parents I know who allow their underage kids to drink with their friends at home with the excuse that the kids are going to drink anyway, and keeping them at home to do it keeps them safe. These are the same parents who smoke pot with their kids with these same excuses. If this is the kind of safety one strives for in this life, I guess addictive, potentially lethal pills prescribed by your doctor are next on the menu.

Dr. Silberstein, Thank you for a well written piece. You obviously understand what Chilmarker will never. Addiction will never be fully understood by anyone but the addicted. Thank you trying to understand and help.

The dynamic of dependency/power between the addict and drug dealer (prescribing doctor) is not healthy. It creates a whole set of added burdens and fears for the addict. It is true that addiction is not fully understood by anyone except the addicted or formerly addicted. Unfortunately, "trying to understand" often boils down to enabling. Touting the replacement of one addicting drug with another also diminishes the courage, work and dedication of all the successful formerly active users. You can fancy up the well-meaning talk and excuses for enabling addicts, but buprenorphine use is still enabling addiction. There is not one word here about a plan for getting the addict off the drug or how expensive it is to maintain the ongoing use of it. Nicotine addiction is extremely difficult to quit, studies say more than opiates, yet even the (expensive) nicotine patches and gum are intended as a stop gap measure. There is an enabling culture of drug and alcohol abuse here, abuse statistically higher than elsewhere. The acceptance of the culture, as is, is promoted by well-meaning parents and doctors and friends. Martha's Vineyard breeds and maintains and covers up substance abuse. Implementing a "non-recovery" solution is part of the continuing problem. Buprenorphine is a good deal for doctors, drug companies, and pharmacies, but for the addict in the long term? Not so much.

As a spouse of an addict i will never fully understand what
an addict feels inside, however i do know that yrs and yrs of knowing my spouse before as a heroin addict and now a recovery addict. ( will always be considered recovering and not a cured addict) i can attest to the fact that my
Spouse who is on suboxone is no longer fighting the demons in his/her head. He/She is living a more than ever thought of normal life here on MV and I can bet hundreds of you have had contact with my spouse and would have all but good things to say about him/ her. He/ she is more of a parent/ spouse than i could ever imagined him/ her could have ever been when going thru those rough yrs. i can truly say this medication has saved my marriage and family! I am so proud and supportive of my husband/wife for everything he/ she has gone thru and who has turned out to be the best person I know. Again like Dr said as you can see it is taboo to even mention to family members what meds my spouse is on to family because of the stigmatism that it holds. You would be shocked to find out who some of these people are that are carrying on with their lives as normal people in this society. You will never know what they went thru to get to were they are today and you will never understand it. I don't care what people think, all i care about is that it works for my spouse and i don't have to cry no more. Proud spouse of a recovering addict